Overnight Summer Camps – The Choices

Are you searching for a new way for your child to spend summer vacation? If so, you should [consider|think about] Children’s Summer Camps , fun and safe places where kids can stay overnight for a period of time that suits you and your child. They can learn more about themselves, meet new friends, appreciate nature, and understand concepts that can be useful in their daily lives. There is a wide variety of overnight camps to choose from for children who want to develop leadership, learn more about nature, put particular skills to use, or just have great fun.

Overnight Summer Camps encourage Campers to participate in different kinds of activities. Whether your child enjoys outdoor activities, playing sports, indoor games, creating art projects, or canoe trips, he or she will surely enjoy time at the camp with other kids discovering new interests. Camp counselors provide guidance and are role models and mentors, adding to what your child has been taught at home and at school.

Before you decide to place your child into an overnight summer camp, it is important to learn a few things about camps in general and the one you choose in particular. Knowing the right information will help you pick the best camp. The following paragraphs are a place to begin. For a complete and comprehensive free guide to choosing the best summer camp for your child, www.summercampadvice.com has been created purely for that purpose and is highly recommended.

Since your child will be staying for a long time at the camp you choose, it is necessary to ensure that the place where they will sleep is comfortable. The cabins, bunks and closets or lockers should be clean and in good repair. The interiors should not be overcrowded and the exteriors should be well-maintained and in good condition. Bathroom facilities should be clean and accessible. The physical facilities of a camp needn’t be new or fancy, and they will not determine the ultimate quality of the experience a camper has, but they can offer hints about the camp directors’ overall attitude and attention to detail.

Much more important to the experience a camper is likely to have at camp is the amount of ongoing individual attention he or she is likely to recieve from staff supervisors and mentors. At least one camp counselor should sleep in each cabin.

The most important factor to consider when searching for a sleep away camp is safety. A good summer camp will offer very thorough information about all matters having to do with camper safety. Here are a few tips to begin with; a complete reference guide for camp safety issues can be found by going to www.summercampadvice.com. Ask about how the camp staff would handle emergencies. The camp should have a clinic with its own nurse. If your child needs special attention or has a special set of medical needs, you should discuss this in detail with the camp administrator. You should inform the directors about your child’s allergies or other health conditions and make sure that the camp will accomodate your child’s particular needs in those areas.

What To Know About Ladies Breeches

Those in the equestrian sphere still like to remain comfortable as they go about their day dealing with horses. There are a range of ladies breeches that can help you do this both in style and comfort. If you look around, you can find a range of stylish jodhpurs.

If you go to a store, yourself, it can be good as you can see the garment in person and you might also be allowed to try it in to ensure that it fits. It is, however, also true that buying online means that you get a much wider range of stores available at your fingertips. There is a reasonable price variation there, too, as well as a number of different styles to look at.

It is true that you have less of an idea about quality before you buy, so this should be kept in mind. However, you can find out about the quality of the breeches as well as the service offered by the employees by reading testimonials. There are, of course, different kinds of jodhpurs out there to suit different needs.

There are, for instance, those pairs for your competition events. There is still a variety within this type, however, so you should still consider what you would like before you choose to purchase anything. You will also find that there are a variety of shades to pick from on most websites that you will find. These will often be very neutral, but you can find some brighter shades if you decide to look for them.

You might, of course, be working towards one kind of color scheme in particular, so it is a good idea to look around and see what suits you the best. Appearances are important, so you should also look for styles you know look good on you. It does, of course, seem like a disadvantage not to be able to try anything one but you very likely already have knowledge of what works for you, and this should help you choose something.

Make sure that you look at the material being used, as well. Since this is a very physical activity, you will need to keep comfort in mind. There is no point in being uncomfortable if you can help it, after all. Price and dispatch times are also things that you can think about, too. You can find some good deals if you look around, of course, and you might save money.

However, it can also be that higher quality items will be of a higher price, so you should definitely watch out for getting something of lower quality if you pay less. You do not want to be in a position where you only have to buy something new, anyway. If you are buying on the internet, you will also need to consider how long it takes to dispatch.

If you order something too late, then it may not arrive at your home in time. Make sure to check the website so that you know what time you should be receiving the garments that you have purchased. You can buy some nice ladies breeches if you take the time to research, first.

What To Consider When Buying A Military Antenna

Many buyers find challenges when looking for electronic goods. This is because they may not have enough knowledge in this field to determine the best specifications of the item they need to buy. This is a common situation for buyers of a military antenna. This is a powerful transmission device that requires proper consideration when buying. One can avoid various hitches by using the following ideas to identify a reliable seller.

It may be helpful to look for the item in person. This is because you have a clear idea of what you want to achieve. Alternatively, you may use your technician or another trusted representative who has proper skills in telecommunication or electronics.

Find out which models are in the market and their date of release. One may consider going for the latest models in the market as these come with superior features that meet current technological development. However, compare the new items with old models to find if the changes are meaningful before buying.

Choose sellers with a variety in their stock, from different manufacturers. This increases your chances of getting what you need. You could compare different models in terms of quality, materials used, transmission strength and others. You could also consider the cost of the antenna and see that you go for what fits your budget.

Find out if the seller may have discounts on any of the models in their stock. This is highly possible with new models which have just been released to the market. They encourage sellers to buy by discounting them. This way, you can easily save money on this important purchase.

Today, one can buy electronic goods from their local stores or using the internet. There are many stores online selling antennas. This makes it easy for consumers to find what the need. Through the internet, one has access to sellers from different parts of the world thus increasing their prospects. In this case, you are not limited when it comes to getting a good quality item within your budget.

Those buying online should exercise great caution as there are cases of cyber crimes targeting internet users. This makes it useful to verify that you are dealing with an authentic dealer. Check if you are buying from the right website before making payments or so. Read reviews from other customers or talk to people who may have dealt with the online seller before.

Ask for a warranty. The sellers whether online or local should be able to provide a comprehensive warranty for their items. Electronic goods have different ways one can offer some warranty to their clients. This could touch on cost, replacement or maintenance for a certain period. It will be helpful to get a written document detailing the form of guarantee, terms and conditions for the same. Make sure you get user manuals or a demonstration on the procedure for setting up the device. Local traders can have their technician installing it for you.

Benefits Of The Services Offered At Horse Riding School Stockton CA

By Jocelyn Davidson

Many of the skills that people normally have are acquired from learning. Being taught is actually one of the major and main ways of learning something. For example if you would to perfect skills in horse-riding then you would be best learning them from someone who knows how to do it. There are many places from where you can actually be able to acquire the skills needed for horse-riding. One of such places is in one of the many horse riding school Stockton CA classes.

These schools do not just accept adults since there are even children willing to learn how to ride horses. If you are a parent, you should consider taking your children in these sessions to prepare them for the future. The good thing with the instructors in these schools is that they know the right steps to follow to become competent rider. You should not therefore deny your children opportunity to learn how to ride these animals.

These sessions are crucial for the development and growth of your children in different aspects. To begin with, your children become quick thinkers once they learn to ride horses. It is evident that children who ride powerful horses with accurate concentration end up with good body workout. When children gear their mind towards the activity, they influence the power to think beyond.

This activity also has physical health benefits to the participants. In the attempt to maintain balance of the body when the horse is in high speed, you are forced to tighten your muscles and joints and this helps you to achieve greater flexibility in the long run. All the people who participate in this game hardly complain of the back pains.

Once you and your children learn how to ride horses, you make the bond between you stronger as you ride. People who ride horse together with their relatives learn to appreciate one another and bond more in love. Children enjoy unusual excitement while they sit on the back of these animals. It makes them appreciate and love their parents more and respect them most.

There is also the bond that is bound to build up between your child and the animal. As much as your kid spends time with horses, he or she will soon be able to learn how to treat and care for the animals. These classes can help one to find out how best to take care of horses. This includes feeding and even grooming them. These are very important skills to learn since they enable you to find out when the animal is not well for example.

It is often a belief that it takes character to ride horses. Most people assume that it is actually very easy. This is however not true. To ride horses you must have the passion for it. This will allow you to have the patience to learn from the animal even as you coach it to react the way you want.

The sessions also teach people how to be patient and disciplined in different areas. Learning to ride horses competently could take some time as you also experience difficulties that associate with it. However, you learn to be patient until you make it to the end.

About the Author:

The Procedure Of Pool Table Refelting Denver

By Lena Stephenson

A pool table is an elegant design used for indoor sports rooms and patios. The game of pool is played as a way of spending leisure time with friends and family. If the tables were to be made of materials that are durable, they can last around twenty years with less maintenance. The most vulnerable component of the structure is the felt. In consideration of pool table refelting Denver residents should know the procedure.

The felt is the fabric which is attached to the surface of the table. When re-felting, the first step is to determine the size of the pool table using a measure tape. The felt is then replaced at a sports shop or home improvement depot. The material should be purchased such that there is an extra 12 inches to the width and length. Because there are many colors, it will be important to decide if the same color as the one being replaced will be used or a different one.

The rails should be removed after that. This is done using a crescent wrench. Bolts attaching the rails are removed. Usually, the rails are also covered by the felt so they will need to be re-felted as well. The rails will then need to be carefully set on the floor close to its position in the table so that a mistake will not be made of attaching the rail to the wrong side.

The felt to be replaced is removed by using a staple remover to pull out staples at the edge of the felt. It will be essential to ensure that all felt is removed from the top of the table. The old one can be placed on a thrash bag from where it can be disposed of later.

The new felt should be placed carefully while making sure to inspect that there are no any damages or stains on it. It should then be cut using a sharp scissor while using the border of the table top as the guide. There needs to be some felt that is left over that will be used for re-felting the rails.

After making the cut, a stapler is used to attach the felt to the top of the table. Stapling begins at the mid points of one end of the felt then proceeds to the left and right edges. When this is done, you proceed to the other end to pull the felt tightly. It then gets stapled like was done in the previous case.

The side edges will then need to be stapled. You should ascertain that the staples are at an equal distance from each other and lined up in the correct way. For the pockets, 3 slits should be cut on every pocket before wrapping and stapling the felt on the edges of the pockets. The felt is tightly pulled prior to stapling.

Finally, the structure is reassembled. Rails will be attached to their original positions using a crescent wrench. The pocket lines are inserted and the table is ready for use.

Lead, Mercury Inhibit Critical Cell Function

Low levels of toxic substances cause critical stem cells in the central nervous system to prematurely shut down. That is the conclusion of a study published today in the on-line journal PLoS Biology. This research, which is the first to identify a common molecular trigger for the effects of toxicant exposure, may give scientists new insights into damage caused by toxicant exposure and new methods of evaluating the safety of chemicals. … Continue Reading

Complete Cleansing System

A War on Patients: Panel Says EHRs Should Not Be Vetted Before Marketing and Deployment

“First, do harm – it’s a learning experience, and injured or dead patients are just a bump in the road, anyway” – the apparent creed of the healthcare computing hyperenthusiasts

Joe Conn and Modern Healthcare published the following article:

Work group says OK to some HIT safety regs (link), Joe Conn, Modern Healthcare, Aug. 7, 2013

What is important is what safety regs the Workgroup said “no” to.  It comes as no surprise:

A federally chartered special work group with representatives from three
federal agencies has submitted its draft recommendations on
establishing a regulatory framework for health information technology.
Chief among those recommendations is that health IT should not be subjected to pre-market federal regulation,
but there were a few exceptions.

The exceptions under which there should be FDA
regulation, according to the work group, include medical device
accessories to be defined as such by the FDA; certain forms of “high
risk” clinical decision support systems, such as “computer aided
diagnostics,” also to be defined by the FDA; and some “higher risk
software” use cases to be defined by the committee’s own safety work
group.


They did acknowledge the need for postmarket surveillance:

… The group also recommended: developing a federally supported,
post-market surveillance system for health IT products “to ensure
safety-related decision support is in place,”
creating a process for
gathering information on safety issues, aggregated at the federal level
and establishing a public process for “customer rating of HIT to enhance
transparency.”

Dr. David Bates [a professor at Harvard Medical School], chairman of the Food and Drug
Administration Safety Innovation Act work group, presented the
preliminary findings Wednesday at a meeting of HHS’ Health Information
Technology Policy Committee.


Let me translate this to plain English:  the health IT systems that go in (and their upgrades and patches) are recommended to be free from pre-marketing regulation and regulatory vetting.  Patients are to be the guinea pigs for testing of the software.  


If patients are harmed or killed, they get the honor of being named as “postmarket surveillance learning cases” who gave their all for the betterment of healthcare information technology.  

(Without their consent, but who needs consent to test experimental and unvetted devices on guinea pigs?)


Bates did express some liability concerns:

Asked during a question and answer period following his presentation
whether the committee had considered the liability implications of its
recommendations
, Bates said, “It’s not something we discussed at length,
but it’s something we can discuss over the next month.”


I, on the other hand, as a legal consultant on health IT-related
medical errors and evidence tampering, am considering liability issues.

Unfortunately, patients would rather be whole than in lawsuits (or dead).  Also, sadly, it’s physicians and nurses who will bear the brunt, if not all, of the liability for bad outcomes due to defective IT such as at these two recent posts, with vendor alerts regarding serious flaws of medication and other orders not being retained:


A clarification for all those proletarians who lack Harvard educations, and for the Workgroup members as well. Allow me to point out that the above manufacturer safety alerts of life-threatening fundamental flaws (involving entered text that “disappears”, apparently found in live-patient scenarios, and the other “glitches” that did cause life-threatening errors sometimes en masse involving thousands of patients such as another apparent Siemens debacle at http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html) would likely not have occurred if the systems had been vetted before being turned loose on patients.
Finally:  David and panel members, my mother and I thank you profusely. 

Oh wait…my mother can’t thank you, she’s dead from the toxic effects of un-premarket-vetted health IT on simple care processes at the very hospital where I performed my residency two decades ago.


She might have died a few times before she actually did thanks to other IT “glitches” that cropped up during her recovery from the first one, but I was able to (in one case, by sheer happenstance of showing up at  the right time) discover or provide staff with information to work around additional unvetted-health-IT flaws before those did her in.

It’s taken more than a decade for critical-thinking, unconflicted writers and researchers (“iconoclasts“)
to force cybernetics-over-all hyperenthusasts (see here) like Bates and his panel members to own up the risks
of health IT at all, e.g. via sites like this blog and this teaching site. These panel members IMO have their heads buried in sand.

Dr. Bates and his panel are, in my opinion, healthcare IT extremists, which is in part the apparent holding of the belief that computers have more rights than patients – and the other beliefs mentioned in this post:  “Another Health IT ‘Glitch’ – Can Digital Disappearing Ink Kill Patients?” at http://hcrenewal.blogspot.com/2013/08/another-health-it-glitch-can.html.

— SS

What the Pfizer (III)? – Enormous Pay for Poor Performance

The recent in-depth investigation by Fortune reporters of 10 years of dysfunctional leadership at Pfizer, the “world’s largest research-based pharmaceutical company,” raises many issues about leadership and governance in health care (see our post here).  To continue what is likely to become a lengthy series, let us now discuss the discrepancy between the markedly dysfunctional leadership performance documented in the Fortune article and the pay given to the leaders involved.

“Hank” McKinnell et al – 2003-2006

Mr McKinell was forced to retire in 2006. The Fortune article described Mr McKinnell as a “desperate CEO” by 2002 because he could find no way to replenish the company’s fading drug pipeline; who then became an absent CEO who “left a power vacuum” and then triggered internal political warfare by setting up a “bitter contest” over succession planning.

The 2006 Pfizer proxy statement reported the total compensation received by Mr McKinnell from 2003-2005.
2003 – $10,706,002
2004 – $11,355,317
2005 – $12,767,270
Each line reflects the combination of salary, bonus, other annual compensation, restricted stock awards, securities underly  options, LTIP payouts, and all other compensation. 
 
The four other best paid executives were Karen Katen, Vice Chairman and President, Prizer Human Health,  David Shedlarz, Vice Chairman, Jeffrey B Kindler, Vice Chairman and General Counsel, and John LaMattina PhD, Senior Vice President, President, Pfizer Global Research and Development.  Their total compensation for these years were
Ms Katen
2003 –  $4,747,478
2004 –  $8,541,220
2005 – $6,663,283
Mr Shedlarz
2003 – $3,722,508
2004 – $6,743,591
2005 – $3,897,293
Mr Kindler
2003 – $3,113,308
2004 – $4,181,817
2005 – $3,338,728
Mr LaMattina
2003 – $2,228,804
2004 – $4,410,130
2005 – $3,558,415

Despite MrMcKinnell’s poor performance, he never received less than $10 million a year in the three years before he was forced out.  Other top managers, despite never effectively compensating for Mr McKinnell’s bad performance earned at least $ 3 million a year in these three years, with one exception, one manager who only made a bit over $2 million in one of the three years.

Jeffrey Kindler et al 2007 – 2010 

Kindler was forced to resign in 2010. The Fortune article also described Mr Kindler as “suddenly desperate” after two failures of drugs in development; someone who “just couldn’t make up his mind,” about acquisitions and spin-offs; “anguished” about research, leading to a “messy” overhaul; and putting “destructive” trust in a subordinate with previously described problems with “character, integrity and divisiveness” leading to loss of the loyalty of the executive team.

The 2010 Pfizer proxy statement revealed the total compensation received by Mr Kindler from 2007-2009.
2007 – $13,075,099
2008 – $15,547,600
2009 – $14,898,038
In this proxy statement, each line included salary, bonus, stock awards, option awards, non-equity incentive plan compensation, change in pension value and non-qualified deferred compensation earnings, and all other compensation. 

The four other best paid executives were F D’Amelio, Chief Financial Officer, I Read, Group President, Worldwide Biopharmaceutical Business, M Mackay, President, Pharmatherapeutics Research & Development, and Dr F Lewis-Hall, Chief Medical Officer.  Their total compensation for these years was:
Mr F’Amelio
2007 – $12,338,821
2008 – $6,979,111
2009 – $7,858,969
Mr Read
2007 – $4,560,869
2008 – $7,629,185
2009 – $9,447,036
Mr Mackay
2007 – $3,590,158
2008 – $6,718,580
2009 – $5,878,806
Dr Lewis-Hall
2009 – $5,087,263 (hired in 2009)

Despite Mr Kindler’s poor performance, he never received less than $13 million a year in the three years before he was forced out.  Other top managers, despite never effectively compensating for Mr McKinnell’s bad performance earned at least $ 4.5 million a year in these three years, with one exception, one manager who only made a bit over $3.5 million in one of the three years.

Summary
 
The business oriented leaders of health care, and some of their sympathizers in health care and policy research are given to preach that “pay for performance,” (P4P) applied to health care professionals is a solution to the problem of ever rising health care costs, and ever declining health care access and quality. 
 
Pay for performance applied to the top hired leaders of health care organizations has become a cruel joke.     The Pfizer example shows a company with chronically bad leadership paid hundreds of times what average workers receive.  Despite a parched drug pipeline and languishing stock price, top managers made millions a year, and CEOs who would eventually be forced out for poor performance made tens of millions a year.  One cannot help but conclude that the main goal of Pfizer was to enrich its top managers.  Managers whose main goal is to enrich themselves, of course, are unlikely to manage well, and unlikely to promote development and manufacturing of drugs whose benefits exceed their harms, and which decrease symptoms, improve function, prevent morbidity, extend life, and generally benefit health.   
 
Now that the scope of the failings of Pfizer’s hired leaders has been made clearer, the company has become one of the best, or worst examples of self-interested leadership and its perils for health care. 
 
As I have repeated endlessly,… health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.
 
If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Virtual Medical Devices and Vendor Liabilities

My essay “Virtual Medical Devices and Vendor Liabilities” was published at the HisTalk website, a website that serves as a healthcare IT industry news/gossip/watchdog site.

It addresses the hold-me-harmless, business IT-type claims made to Sen. Grassley by some healthcare IT vendors that they are “not liable when harm or loss results from the client’s use of the product in diagnosing and/or treating patients” (as indicated in Sen. Grassley’s question 9 to hospitals here).

This is a somewhat absurdist claim, since these systems are not exactly sold to allow clinicians to play Super Mario:

Play games with our EMR, but use it to diagnose and treat patients at your own risk!

I make the point in my essay that an EMR and other clinical IT systems are virtual medical devices, that is, medical devices that happen to reside on a computer, and that healthcare IT vendors are indeed practicing medicine by cybernetic proxy (e.g., in provision of alerts and reminders and clinical decision support).

I also pointed out that a vendor claiming they are not liable when harm or loss results from the client’s use of the product in diagnosing and/or treating patients should put that disclaimer on every screen of their products.

Ultimately, I opine that if a healthcare IT vendor claims to be a partner to clinicians and clinical medicine, they should be willing to accept the responsibilities that accompany such a position and their claims of omnipotent ecstasy about healthcare IT “transforming” or “revolutionizing” healthcare.

See the essay at this link.

— SS

More Questions About Conflicts of Interest and "Surviving Sepsis"

Two years ago, we posted about questions whether the “Surviving Sepsis” campaign was driven by marketing as well as science. Then, we discussed a commentary in the New England Journal of Medicine which asserted that the campaign was part of an effort by Eli Lilly & Co to market Xigris (recombinant human activated protein C, or rhAPC, also known as drotrecogin alfa [activated]) for the treatment of sepsis.(1)

The Wall Street Journal just published an article questioning another aspect of that campaign. In 2001 a clinical trial in the New England Journal of Medicine by Rivers et al reported favorable results for early goal-directed therapy in the treatment of sepsis.(2) This therapy incorporated continuous monitoring of oxygen in the blood using a special central venous catheter capable of measuring oxygen saturation. The WSJ article first raised concerns that some of the patients initially entered into the study were excluded after randomization.

The medical-journal article analyzed 263. But it also said that 288 patients were ‘evaluated,’ of whom 25 ‘were excluded or did not consent to participate.’

Dr. Rivers, in an April interview describing how he proceeded, said ‘all 288 are randomized’ — that is, placed into either the standard-therapy group or the other group — ‘and then some are excluded because they’re not considered severe septic shock.’

But once patients are randomly placed in a group, they must be included in a final analysis, according to a fundamental principle of medical research. Twenty-five were not, the medical-journal article makes clear.

Further muddying the waters, Dr. Rivers, despite having said all 288 patients were ‘randomized,” stated in a later email that ‘there were absolutely no patients pulled out before the analysis.’

The result appears to be a lack of clarity about exactly how this seminal study was done.

Hospital statisticians who worked on it had concerns about the data and recalculated the results with all 288 patients, according to people familiar with the events. When they did, these people say, the death-rate gap wasn’t statistically significant.

Statisticians were especially concerned when they noticed that a relatively high proportion of the other 25 — those not included in the final analysis — were either conventional-therapy patients who survived or patients on aggressive therapy who died, say the people familiar with the events.

In 2005, a medical resident at Henry Ford doing follow-up research complained to senior hospital officials about the data in Dr. Rivers’s study. The hospital convened a panel of inquiry, which concluded the issues had been satisfactorily resolved, hospital officials say.

The panel did a ‘thorough investigation’ and ‘unanimously supported the conclusions,’ the hospital said, adding that Dr. Rivers is ‘an outstanding clinical investigator whom we support.’

The hospital declined to make the panel’s report available. The medical resident who complained, Michael Donnino, declined to discuss the issue of the other 25 patients not included in the final analysis.

Dr. Rivers said that ‘randomization was valid,’ that ‘all patients enrolled in the [early goal-directed therapy] study were appropriately selected, randomized and examined statistically,’ and that ‘there are no scientific integrity issues in the study.’

I should note that ideally randomized controlled trials should account for all patients randomized, and attribute their results to the group in which they were randomized, even if they did not complete the treatment to which they were randomized. Eliminating patients after randomization could bias the results of analysis, especially if patients particularly likely to have good or bad outcomes were selectively eliminated from one group or the other. The WSJ article raises questions about the occurrence of such bias, but does not prove it occurred.

Further complicating things, the WSJ article suggested that the authors of the article also had undisclosed conflicts of interest.

At the time the study at Henry Ford Hospital was published, in late 2001, the hospital was the owner of patents on the catheter used in the new treatment. Dr. Rivers had transferred the rights to the institution.

The New England Journal of Medicine didn’t mention the patents when publishing the study. According to its editor, its policy at the time was to ask only whether an investigator had financial ties to companies involved, and Dr. Rivers said, correctly, that he had none.

Since the publication, catheter maker Edwards Lifesciences has made various payments to Dr. Rivers and his hospital. Such arrangements aren’t unusual in medicine, but their existence can raise doubts about findings.

Dr. Rivers and the hospital over the years have received at least $404,000 from Edwards, the Irvine, Calif., company says.

For instance, Edwards paid $150,000 between 2001 and 2003 to Henry Ford Hospital for what Edwards terms ‘nonexclusive patent rights [and] ongoing research‘ into blood oxygen and the mechanism of shock. Dr. Rivers, in an interview, described this as ‘money I’ve gotten from the catheter…all for research.’

In addition, Edwards said, it has paid Dr. Rivers $158,000 to make speeches about his research, $20,000 to reimburse him for patent legal fees, $36,000 in reimbursed expenses and $40,000 in consulting fees.

Edwards Lifesciences said medical evidence has ‘demonstrated that early goal-directed therapy yields significant reductions in sepsis-related mortality, lower organ failure rates and/or reduced health-care costs, particularly due to reduced stays.’ In recent articles he has written, Dr. Rivers has disclosed receiving support from Edwards.

Also, Edwards Lifesciences was, along with Eli Lilly, a major sponsor of the Surviving Sepsis campaign.

In 2002, critical-care doctors from several specialties joined together to recommend treatments, calling themselves the Surviving Sepsis Campaign. Leading it were R. Phillip Dellinger of Cooper University Hospital in Camden, N.J., and Mitchell M. Levy of Brown University Medical School. Both, plus four others in the group, received consulting fees, honoraria or research-grant support from catheter maker Edwards.

Edwards helped pay for overseas meetings of the group in 2002 and 2004, which cost $861,000 in all. Surviving Sepsis endorsed Dr. Rivers’s protocol as well as a drug made by another funder of the conferences, Eli Lilly & Co. Edwards said such support is ‘routinely given to advance science and treatments for the benefit of patients.’

Finally, Dr Rivers also has also recently disclosed that he has been receiving money from Eli Lilly, for example, in a 2006 article, “Dr. Rivers has done consultant work for Biosite, Inc., Chiron, the Lilly Corporation, and Edwards Lifesciences over the last year.”(3)

So, for an interval summary, recent guidelines promulgated by the “Surviving Sepsis” campaign include fairly enthusiastic endorsements for use of Xigris, made by Eli Lilly & Co, and early goal directed therapy, which requires use of a specific catheter made by Edwards Lifesciences (and other companies). These guidelines were based on research sponsored by these two companies which the guidelines touted as more definitive than it now appears to be. Furthermore, there is a web of financial links, that now appears increasingly complex, tying together these two companies, some researchers involved in these studies, their institutions, and the guideline writing process. These apparent conflicts of interest have raised questions about the integrity of the research on which the guidelines were based, and bias influencing the writing and deployment of the guidelines.

So it is becoming more difficult to determine the extent that marketing considerations influenced the “Surviving Sepsis” campaign, and some of the medical research on which its guidelines were based. Thus, the issue of how best to manage sepsis, already a complex one, now becomes more complex and less clear.

The larger lessons, again, are that there is a growing and ever more pervasive web of financial ties among academic medicine and commercial firms that make drugs and devices and provide various health care services. The resulting conflicts of interest suggest patients, physicians and policy-makers should be ever more skeptical about seemingly authoritative medical research, and medical education, practice guidelines, and health care policy based on this research.

To make better decisions for individual patients, and better policies for populations, people, patients, physicians and policy-makers at least need clearer and more detailed information about all conflicts that may affect the evidence and opinions that influence their decisions. But might it not be simpler and ultimately better for people, patients, physicians and policy-makers to eliminate some of these conflicts so that we can begin to believe that researchers and academics are paid only to take care of patients, and create and disseminate new knowledge?

References

1. Eichacker PQ, Natanson C, Danner RL. Surviving sepsis – practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med 2006; 335: 1640-1642. Link here.

2. Rivers E, Nguyen B, Havstad S et al for the Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377. Link here.

3. Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: converting science to reality. Chest 2006;129:217-218. Link here.